Safety Of Trauma And Local Tumor Effect After High-intensity Focused Ultrasound Ablation Of Uterine Fibroid

BackgroundSurgical trend is the development of surgical treatment based on less damage tohuman. High intensity focused ultrasound (HIFU) is a non-invasive therapy of tumouremerged in recent years, it provides non-invasive treatment with precise positioning andno incision. Uterine fibroid is the most common benign tumor of reproductive system.Uterine fibroids are treated with HIFU by focusing ultrasound energy to local fibroidtissue and cause coagulation necrosis and prevent the growth of uterine fibroids.Along with HIFU therapy is widely applied in the treatment of uterine fibroids,clinical observation reports on safety of HIFU represented by many centers. However,there is no safety evaluation based on the characteristic of HIFU,"no invasive",especially compared with traditional treatment. Ultrasound ablation of uterine fibroids isa noninvasive treatment characterized by retaining uterus, no surgery and no anesthesiamethods, as well as the principle of the treatment is practicing within tumor to avoidaffect neighboring tissue. Considered under the non-invasive characteristic, safetystudies on HIFU ablation is to evaluate the trauma on human compared with traditionalsurgery. The purpose of study was to evaluate the safety of the new technology, and toinvestigate the security of residual untreated tumor (non-target tumor tissue) after HIFUablation and related mechanisms.This study was designed to study the trauma of HIFU ablation with controlledclinical trials for assessment of noninvasive techniques. Meanwhile, we explored therelated factors affected non-target tumor tissue, evaluated clinical safety evidence of local tumor and built the prediction model of non-target fibroid tissue by follow-up andanalysis of clinical imaging data on HIFU ablation target of uterine fibroids. The studywas to explore the possible mechanisms of local tumor based on clinical data, andconcluded laboratory evidence of local tumor effects. The study provides a clinical andlaboratory basis to evaluate the safety of HIFU ablation for uterine fibroids. It alsoprovides a scientific basis of HIFU therapy for planning and optimizing treatmentprogram.Objective1. To evaluate trauma on the body of HIFU ablation for uterine fibroids and abdominalmyomectomy.2. To study the outcome of residual tumor (non-target fibroid) and influencing factorsby analysis of clinical data, and explore the local effect of non-target fibroid after highintensity focused ultrasound ablation for evaluation the safety of HIFU therapy.3. To explore the preliminary mechanism of high intensity focused ultrasound ablationon non-target fibroid.Research content1. Based on clinical observation and trauma-related serum markers, the study wasdesigned to evaluate the trauma of HIFU on patients compare with abdominalmyomectomy through randomized controlled trials (RCT).2. To explore the related factors affected non-target tumor tissue, evaluated clinicalsafety evidence of local tumor and build the prediction model of non-target fibroidtissue by analysis of clinical imaging data.3. To explore the relationship of the outcome of non-target fibroids and ablation ratebased on the regression model. It can be initially proposed the treatment program toacquire clinical outcome of non target fibroids.4. To explore the effect of HIFU on the expression of regulatory factors on growth ofnon-target fibroid tissue and related mechanisms by building HIFU ablation isolated human uterine fibroids model.5. To explore the he effect and mechanisms of HIFU on human fibroid cells within thesound field of ultrasound with cultured primary human fibroid cell model.Material and MethodsPart one1. ObjectiveFrom September2010to December2011,253patients diagnosed with uterine fibroidand scheduled for surgery were enrolled in the1st Affiliated Hospital of ChongqingMedical University2. EquipmentsJC focused ultrasound tumor therapy system (Chongqing HIFU Technology Co., Ltd.)Magnetic resonance imaging system Magnetom Symphony1.5T MR Tim (Siemens,Germany)3. Methods1)188patients who meet the inclusion criteria were randomly assigned to high-intensityfocused ultrasound ablation group (HIFU group) and abdominal myomectomy group(myomectomy group) with RCT (block randomized method). The indicators for clinicalsafety were observed, including vital signs, postoperative recovery time, surgicaladverse events and complications.2)31cases were randomly selected from188patients. All patients was detected withsurgical trauma indicators of peripheral blood before and after therapy, including:(1)cortisol, epinephrine and norepinephrine;(2) IL6, IL2, and IL10;(3) peripheral bloodwhite cell counts, neutrophil percentage and hemoglobin values;(4) CD4+, CD8+andNK ratio of peripheral blood.4. Statistical methodsSPSS16.0package was applied for statistical analysis.Part two1. Objective Clinical data of96patients treated with HIFU of uterine fibroids from January2007toJanuary2010.2. EquipmentsJC focused ultrasound tumor therapy system (Chongqing HIFU Technology Co., Ltd.)hifu-3DTPS Microsoft Foundation Classes application software (Chongqing HIFUTechnology Co., Ltd.)3. Methods1) Automatic3D reconstruction and calculation of non-target fibroid volume withsoftware. Analysis of the impact factors on shrink rate of non-target fibroids forestablishing predictive regression model of outcome.2)96patients with HIFU were assigned to each group according to different ablationratio. We compared the imaging outcome of each group to find out the "inflection point"of ablation ratio affect the trend of non-target fibroid.4. Statistical methodsSPSS16.0package was applied for statistical analysis.Part three1. Objective1) Human uterine fibroid: From April2010to November2010,8cases were appliedwith hysterectomy and subtotal hysterectomy due to uterine fibroid. The age was40.2±3.9(35-47) years. The signals of pre-operative T2WI in all patients were uniformly lowsignal. Average volume of uterine fibroids were48.35±12.02cm3(37.1-65cm3), andmaximum diameter was4.38±0.33cm (4.2-5.1cm). The fibroids were confirmed bypathology after surgery, and fresh uterine fibroids were received with ChongqingMedical University Ethics Committee approval and patient consents.2) Primary uterine fibroid cell: From April2010to October2011, human uterine fibroidspecimens were taken from patients of39-45years in gynecological department of the1st Affiliated Hospital of Chongqing Medical College. All patients were not takinghormone treatment within three months before surgery. The fibroids were confirmed bypathology after surgery, and the fresh fibroids were immediately sent to the laboratory for culturing primary cell.2. EquipmentsJC focused ultrasound tumor therapy system (Chongqing HIFU Technology Co., Ltd.)Magnetic resonance imaging system Magnetom Symphony1.5T MR Tim (Siemens,Germany)ELISA analyzer (Ningbo Institute of Automation Instrumentation)3. Methods1) To establish the model of isolated human uterine fibroids with HIFU ablation, andstudy the effect of HIFU on expression of estrogen receptor, progesterone receptor andP450in non-target fibroid tissue.2) To build HIFU sonication model of cultured primary human uterine fibroid cellwithin the sound field by filtering the smallest ultrasound parameters which can causetarget uterine fibroid cell death. To study the mechanism of the effect of ultrasound oncells within the sound field by analysis of different impact of focused ultrasound on thecells represented within different distance to ultrasonic focus.4. Statistical methodsSPSS16.0package was applied for statistical analysis.ResultsPart one1. Clinical safety indicators were observed in HIFU group and myomectomy group. Theresults showed: Compared with myomectomy group, HIFU group had less impact onpostoperative body temperature, systolic blood pressure. Less surgical complicationsand adverse events, shorter recovery time can be found in patients of HIFU group. Nosignificant difference of the postoperative pain score was found in two groups.2. The effect of HIFU and myomectomy group on the levels of trauma-relatedserological markers:(1) No significant changes of postoperative serum cortisol,epinephrine and norepinephrine concentrations were found in two groups significantly;(2) Patients in myomectomy group affected the levels of serum IL-6, IL-2, IL-10 significantly, especially within24hours after surgery;(3) WBC counts, neutrophil ratioin myomectomy group were higher than HIFU group, postoperative hemoglobin valuewas significantly lower than HIFU group;(4) The ratio of CD4+, CD8+and NK cellswas inhibited in myomectomy group significantly compared with HIFU group.Part two1. Correlation results of shrink rate of non-target fibroids with multivariate factorssuggest that: The factors which influence the outcome of non-target fibroids includedblood flow grade of uterine fibroid, signal of T2WI, non perfused volume ratio. Theregression model was:[=Non-target fibroid volume reduction ratio,Χ1=ultrasound ablation rate (%), χ2=uterine fibroids flow grade, χ3=uterine fibroids T2WI signal conversion value]2. The result of observing on the imaging outcomes of groups with different non-perfused volume ratio (NPV) showed satisfied imaging outcome can be get withnon-target volume less than30%of target fibroid.Part three1. Different degrees of temperature rise in non target fibroid tissue outside target fibroid,and temperature decreased gradually along with the distance outside target area.Compared with the control group, no significant difference was found in the expressionof estrogen receptor and progesterone receptor in non target fibroid.Immunohistochemical staining and Western blot semi-quantitative detection ofP450arom protein represented at0.5cm and1.0cm outside target area showed lowerlevel significantly than the control group, the difference was statistically significant.2. Primary human uterine fibroid cell was successfully cultivated. Smallest ultrasonicparameters (power200W,5seconds) lead to cell death was screened ultrasoundparameters of cells positioned in focus. High intensity focused ultrasound can induceuterine fibroid cell apoptosis positioned within sound field. The occurrence of apoptosisand apoptosis rate was related with the distance from focus. Different degree of caspase-3activation appeared in cells within sound field, and the expression ofcaspase-3the strength was related with the distance from focus.Conclusions1. Compared with myomectomy group, the result of HIFU group showed smallertrauma on patients.2. Outcome of non-target fibroids was related to NPV. NPV of more than70%can beobserved to get satisfactory outcome of non-target uterine fibroids.3. The growth of non-target fibroid within a certain range will be suppressed after HIFUablation part of uterine fibroid, and the mechanism was related to P450protein affectedby temperature.4. HIFU can induce uterine fibroid cell apoptosis positioned within the sound field. Andthe occurrence of cell apoptosis was related with the distance from focus, themechanism of apoptosis may be associated with activation of caspase-3.